Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is a type of cognitive-behavioral therapy. DBT was originally developed in the 1980s by Marsha Linehan, a psychologist at the University of Washington. Although initially intended to help chronically suicidal individuals diagnosed with borderline personality disorder (BPD; please refer to the accompanying fact sheet for information on BPD), DBT has since been adapted for and used to effectively treat a number of other psychological problems. The central dialectic within DBT is to balance acceptance of the person exactly as s/he is in this moment with intense efforts to change the person’s life to increase adaptive functioning and decrease maladaptive behavior. The overarching goal of treatment with DBT is to help individuals develop, as Dr. Linehan would say, “a life worth living.”

What Does DBT Involve?

Since DBT was developed for individuals with severe and persistent suicidality [for more information on suicide, see ABCT’s fact sheet on suicide], it tends to involve greater commitment on the part of therapists and clients alike to work towards developing a satisfying and meaningful life so suicide does not appear to be a good alternative to living.

In its standard, outpatient form, DBT has four major components:

1. Weekly individual (one-to-one) therapy

2. Weekly skills-training sessions, usually in the form of groups

3. As-needed consultation between client and therapist outside of sessions

4. Weekly therapist consultation meeting in which DBT therapists meet to discuss their DBT cases

Individual therapy occurs at least once a week. The content of the therapy session generally revolves around targeting a high-priority event that occurred within the past week, helping the individual identify all the factors that led up to and followed the event (via a process called “behavioral analysis”) and then determining and practicing new ways of responding in the similar situations. The skills-training component of DBT involves teaching the individual specific skills designed to help improve their life in four major areas: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. Therapists make themselves available between sessions for consultation to help the clients apply new skills to prevent the use of problematic behaviors. Finally, the weekly consultation team is designed to help therapists get the support they need for treating suicidal clients as well as increase their motivation and adherence to DBT principles.

It is important to note that any facility or clinician that does not offer all of these four major components, is not offering comprehensive DBT. Rather, they are providing an adaptation or modification of DBT. Although this type of adaptation is quite common in the community, unfortunately we do not yet know whether just one (or two or three) component of DBT is as effective as the whole package.

Psychotropic medications are also often used to treat symptoms of BPD and associated problems, in conjunction with DBT, though research on their effectiveness is limited and we really don’t know whether medication works. Although not opposed to the use of medications, the stance of a DBT therapist is generally to help the individual learn to “replace pills with skills.”

Who Is DBT for?

DBT was originally developed for individuals who suffered from borderline personality disorder, a psychological condition in which people have great difficulty managing their emotions. DBT has also been adapted to treat other psychological problems including: eating disorders (specifically bulimia nervosa and binge eating disorder), suicidal and self-injurious behavior in adolescents, treatment-resistant depression, and substance use problems that cooccur with BPD. It is important to note that the reason DBT has been adapted for those different disorders is because each of these conditions is theorized to be associated with problems that stem from maladaptive efforts to control intense, negative emotions.

Is DBT Effective?

There have been numerous studies designed to determine whether DBT is effective, compared to treatment-as-usual and other, more rigorous control conditions. Studies on DBT for BPD indicate that DBT is an effective treatment for reducing suicidal behavior and non-suicidal self-injurious behavior, reducing hospitalizations and ER visits, and decreasing depression and anxiety. There are fewer studies on DBT for the other disorders listed above; however, pilot studies indicate that DBT is effective at reducing core symptoms of those disorders (e.g., binge/purge episodes in bulimia and substance use frequency in substance use disorders).

How Long Does DBT Last? How Soon Can I Expect Changes?

The research studies conducted on DBT for BPD have all included one year of treatment or less. Unfortunately, this does not mean that individuals should expect to be completely free of symptoms or no longer have problem behaviors at one year. Most clinicians, including Dr. Linehan, the developer of DBT, believe that treatment for BPD can often take several years. However, the research does suggest that “behavioral control”, that is the absence of suicidal behaviors and other life-threatening behaviors as well as severe qualityof- life interfering behaviors, can often be achieved within four to eight months of comprehensive DBT.

As mentioned, there are far fewer studies on DBT for other conditions; however all such adaptations are shorter than one year and suggest that improvement can be achieved more rapidly.

Finding a DBT Therapist

Finding the right therapist is often a time-consuming task and DBT therapy is no exception. It is important to make an educated decision about choosing to work with a particular therapist based on experience, qualifications, and degree of “match.”

Some questions to ask a potential DBT therapist:

1. What is the nature of your training in DBT?

Some possibilities include attending an “intensive training” through Behavioral Tech, a training company founded by Dr. Linehan (see below), receiving training in graduate school or postdoctoral work, or receiving “on the job” training at an institution or agency. It is usually important that someone receive significant supervision by someone considered an expert in DBT.

2. Do you provide comprehensive DBT or a modification? If not comprehensive DBT, why not?

If a person has BPD or significant suicidality, it may be important to receive comprehensive DBT because that is currently the gold standard for those conditions.

3. Do you belong to a DBT consultation team? Who are the other members of your team?

Attendance at a consultation team is a crucial aspect of DBT. If a therapist does not regularly attend a consultation team, they are not doing comprehensive DBT.

4. What is your policy on phone calls/emails during the week?

While there is no “right” answer to this question, potential clients should know upfront whether phone calls and other forms of communication are accepted during the week. If the therapist states that he or she does not accept these forms of communication, it is important to inquire how skills generalization may occur (i.e., how the client might receive skills coaching at times other than the therapy hour).

5. What length of time do you initially ask a client to commit to?

Again, there is not a “right” answer here. However, it is useful for the therapist and client to mutually agree on an initial length of commitment (e.g., three months, six months, one year) prior to beginning therapy. Then, once the initial commitment period has ended, the therapist and client can evaluate gains made over that time and whether it would be fruitful to commit to another treatment period.

In addition, here are a couple of other resources that may be of use in finding a DBT therapist:

• Behavioral Tech, LLC (www.behavioraltech.org): Behavioral Tech is a training company, founded by Marsha Linehan. It is not the only company that provides training in DBT. However, the Behavioral Tech website offers a number of resources on DBT including fact sheets, referral information, and training opportunities for clinicians. Specifically, they have a Clinical Resource Directory, which lists teams of clinicians that have received training from Behavioral Tech in DBT that interested parties can search to find potential therapists in their region.

• TARA Association for Personality Disorders (www.tara4bpd.org): The mission of TARA is to “to foster education and research in the field of personality disorder, specifically but not exclusively Borderline Personality Disorder (BPD).” They publish a brochure entitled “Guidelines for Choosing a DBT Therapist” which can be found here